FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466.6781 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and,or install the work herein described. This applicaUnn is made in complianco with San Joaquin C,ouriry ordinance No.549 for sews{1e or No. 1862 for well/Dump and the Rules and Regulations of me San Joaquin Local Health District./�PN 040 -03 _ _ StA) jvim,,lr✓ N 2 9A C_Job Address �� 2L City— Lot Siie •----- PM kev/{(`) liver Owner's Name Gl'v. OQ.s�� 11 ,dL_ o _ Addross ?z9/ 6l) K4A1c4 Lane Sv�� Phone zoli1u �— /V-- -� 's /vc /o-i 61 y/-, E06f�rat. /V- r��h� CaRfitet•tof ,�?�/Ile c4 �r[. Address�ldol'Uwf.( _r nt ✓�. License NO. ��. Phone _�5� 'f�D� TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT F. DESTRUCTION a H —' —" OTHER PUMP INSTALLATION 0 SYSTEM REPAIR C DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES __.—. — DISPOSAL FLD._ ... PROP. LINE _..— FOUNDATION AGRICULTURE WELL __:.—_. OTHER WELL_ PITS/SUMPS — INTENDED_ U_SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— I'! Industrial Li Open Bottom C1 Mantoca Dia. of Well Excavation oia. of Well Ca inq _ I i Domestic/Private f-i Gravel Pack 1-7 Tracy Type of Casing _ Specifications I; Public i I Other r-I Delta Depth of Grout Seal — Type of Grout I I Irnlldtiort _ Approx. Depth I I E85ten1 Surface Seal Itl5talled by Repair Work Done I., Type of Pump _ H.P. State Work Done ---•- --— I Well Destruction L I Well Diameter Sealing Material (top 501 — ---. Depth —. Filler Material (Below 501 - -- — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DES'I11OCTION 1 1 iNo septic -syVenl thin 100 emit?L11 if puhl+C sower is available w <' Installation will serve: Residence _ Commercial_ Other Number of living units: -— Number of bedrooms— _ Character of soil to a depth of 3 feet: Water table depth — SEPTIC TANK i1 Type/Mfg Capacity_-. No. Compartments PKG. TREATMENT PLT. LI Method of Disposal 171 Distance to nearest: Well— Foundation — — Property Line _ Yi LEACHING LINE I.I No, & Length of lines _—_ Total length/size—. -- --- -- /' FILTER BED PI Distance to nearest: Well—„ Foundation Property Line -.. SEEPAGE PITS I I Depth _Size ._-.--_ __—•• ._— Ntimber SUMPS i I Distance to nearest: Well_ — Foundation _. —__.— Property Lina - DISPOSAL PONDS 1 i 1 hereby certify that I have prepared this application and that the work will be done In accordance with Sart Joaquin county ortlindacas, State tavfs• dn1 rules and regulations of the San Joaquin Local Health Di3triet. A Home owner or licensed agent's signature certifies the following: "1 certify that in the perlortnance of the work for which this perm,t •s issues, I Shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting sigoawre certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subiact to.v�rkmdn's COmpQnSb tion laws of California." -�/ 'L''\ /', 1 rt �• /� The applicant must call for all required inspections, Complete drawing on reverse side. I Signed Title:S_a17It) L_�� `LJ Pate: FOJHPPAR USE ONLY Application Accepted by Date. )Are8 4 Pit or Grout Inspection by _ Date Final InspectiorL'b �. ---- Additional Comments: — l.i Stk 466.6781 ❑ Lodi 369-3621 O Manteca 823.7104 ❑ Tracy 1335-6386 Applicant • Return all copies to: Environmental Health permit/Services 1601 E. Hazelton Ave„ P.O. Sox 2009, Sik., CA 95201 FEE AMOUNT OUE AMOUNT REMITTED CASHRECEIVED AY GATE PEH�ti1 NO INFO —�--- St _ r»ti.:t IREV �,,,,